W12-Geriatric Case Study

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GERIATRIC CASE STUDY

Post#2

Week 12 Discussion 1: Geriatric Case Study

Assessment

After a keen evaluation of the patient, she is suffering from Bipolar I Disorder and moderate dementia. The patient suffers from Bipolar I Disorder because she meets the criteria for its diagnosis. According to the DSM-5 criteria, in Bipolar I disorder, the manic episodes may be preceded by or may be followed by hypomanic or major depressive episodes. During the hypomanic episodes, there is increased energy or activity characterized by inflated grandiosity, racing thoughts, or flight of ideas (American Psychological Association, 2013). Hypomanic episodes are also characterized by distractively and excessive involvement in hazardous activities. In our case study, the patient is cantankerous and opinionated. The patient's caregiver also reports that her behaviors are agitated and oppositional. Besides, according to the DSM-5 criteria, individuals with bipolar disorder present with manic episodes characterized by unreasonable euphoria, very intense moods, hyperactivity, and delusions (American Psychological Association, 2013). In our case study, the patient presents delusions; she refuses most cares and is paranoid that her caregiver is speaking about her whenever she is talking on a phone. The patient also argues with other participants in the day program such that she threatens to be sent out of the program.

Additionally, individuals with Bipolar I disorder present with depressive symptoms, including loss of happiness, lack of sleep, insomnia, and poor concentration. In our case study, the patient resisted sleep, staying up late, and waking in the middle of the night. Based on all these symptoms, the patient is suffering from bipolar I disorder. 

Besides, the patient has moderate dementia because she meets its criteria for diagnosis. According to the DSM-IV criteria, individuals with dementia presents several cognitive deficits in addition to memory impairment. In various studies, memory impairment may be the only clinical finding, but it cannot be the only factor to consider when determining whether an individual has dementia (Groot et al., 2016). To affirm that an individual has dementia, one must portray deficits in social and occupational functioning, with the functional impairments portraying a decrease in the patient's usual ability. In our case study, the patient displays multiple social functioning deficits. She refuses most care offered by the caregiver and is always oppositional to whatever information she provides. The patient also argues with the other participants in the program that she threatens to be kicked out of the program. With such symptoms, she has moderate dementia. 

Treatment plan

           The treatment plan incorporates all the pharmacotherapy and psychotherapy options that can help the patient manage the severity of the symptoms. To address the manic and hypomanic symptoms, the provider can continue Depakote. However, the patient should start with an initial dose of 750 mg/day PO in divided doses (Stahl, 2017). For the Depakote ER initial dose, the patient can take 25 mg/kg PO once daily. This can be increased as rapidly as possible to achieve the lowest therapeutic dose that provides desired clinical effect. However, it should not exceed 60 mg/kg/day. Depakote is an excellent medication to treat bipolar symptoms because it increases the concentration of gamma-aminobutyric acid (GABA) and inhibits histone deacetylase in the brain to minimize manic symptoms. 

           To manage the MDD symptoms, the provider can continue Bupropion. For the Immediate-release tablets, the patient can start with an initial dosage of 100 mg twice a day, which can then be increased, if necessary, after three days to 100 mg orally three times a day (Stahl, 2017). The maintenance dosage is 100 mg orally three times a day, and the maximum dosage is 450 mg/day in up to 4 divided doses. Single doses should not go beyond 150 mg. Bupropion inhibits norepinephrine and dopamine reuptake, resulting in more of these neurotransmitters in the brain. This minimizes depressive symptoms such as lack of sleep. 

           In addition, the provider can introduce another medication to address the dementia symptoms that the patient exhibits. A suitable medicine that can help address dementia is Aricept (Donepezil). When taking this medication, the patient can start with an initial dosage of 5 mg PO qHS, which can be increased to 10 mg qDay after 4-6 weeks if required) (Stahl, 2017). If the symptoms become severe, the dosage may be further increased to 23 mg/day after three months. Donepezil should be integrated into the plan because it would help reduce memory impairments and improve social functioning. 

           On the other side, Cognitive Behavioral Therapy (CBT) needs to be incorporated into the treatment plan to help the patient manage the symptoms. CBT is effective in patients with bipolar disorder because it decreases relapse rates. Besides, this medication improves mania/hypomania and depression symptoms and enhances the patient psychosocial functioning. CBT helps patients identify their negative thoughts, emotions, and behaviors and change them from positive to negative (Newman, 2021). This means that with CBT, the patient will be able to identify her aggressive behaviors, paranoia, and other negative thoughts and change them from negative to positive, eventually recovering from bipolar disorder. 

           Finally, the patient will be referred to other specialists such as family therapists to improve communication with other people, such as her caregiver. For the follow-up, the first one should be in a week, then in two weeks, depending on her progress. 

References

American Psychological Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). (DSM-5). ISBN-13: 978-0-8904-2555-8.

Groot, C., Hooghiemstra, A. M., Raijmakers, P. G., van Berckel, B. N., Scheltens, P., Scherder, E. J., ... & Ossenkoppele, R. (2016). The effect of physical activity on cognitive function in patients with dementia: a meta-analysis of randomized control trials. Ageing research reviews, 25, 13-23.

Newman, C. F. (2021). Bipolar disorder. American Psychological Association.

Stahl, S. (2017). Stahl's essential psychopharmacology prescribers guide (6th ed.). Cambridge University Press.